<!-- intestazione uguale per tutti -->
<!DOCTYPE html>
<html>
  <head>
    <meta charset="utf-8">
        <title>Vaccini</title>
        
    <!-- Le styles -->
    <link href="styles/style.css" rel="stylesheet">
    <style type="text/css">
      body {
        padding-top: 30px;
        padding-bottom: 30px;
        background: #ffffff;
      }
    </style>
  </head>
  <!-- fine intestazione - inizio pagina -->
  
    <body>
        <div class="container-fluid-large">
            <div class="row-fluid">
                <form action="Registration" method="post"> 
                        <div class="row-fluid show-grid">
                            <div class="span12">
                                <p class="lead">Registrazione</p>
                                Benvenuto! <br> 
                                <small>Questa pagina viene chiamata la prima volta che accedi al sito. <br> 
                                    Inserisci qui di seguito i tui dati.</small>
                                <input type="hidden" name="typeUser" value="patients">
                            </div>
                        </div>
                        <hr>
                        <div class="row-fluid show-grid">
                            <div class="span4">
                                <h6>Nome Cognome</h6>                       
                                <input type="text" name="name"  placeholder="name"/>
                                <br> 
                                <input type="text" name="surname"  placeholder="surname"/>    
                                <br>
                                <h6>Data di nascita</h6>
                                <input class="input-mini" type="text" maxlength="4"  name="date_year" placeholder="year">
                                <input class="input-mini" type="text" maxlength="2" name="date_month" placeholder="month">
                                <input class="input-mini" type="text" maxlength="2" name="date_day" placeholder="day">
                                <br>
                            </div>
                            <div class="span4">
                                <h6>Username</h6>
                                <input type="text" name="old_username" placeholder="username"/> 
                                <br>
                                <small>Inserisci una nuova username<br>(se non vuoi cambiare lascia in bianco)</small>
                                <input type="text" name="new_username" placeholder=""/> 
                                <br>
                                <h6>Password</h6>
                                <input type="password" name="old_password" id="inputError" placeholder="password"/>
                                <br>
                                <small>Inserisci una nuova password<br>(se non vuoi cambiare lascia in bianco)</small>
                                <input type="password" name="new_password" id="inputError" placeholder=""/>
                                <br>
                                <small>Reinserisci la nuova password</small>
                                <input type="password" name="new_password_cheak" placeholder=""/> 
                            </div>
                            <div class="span4">
                                <h6>Inserisci la parola qui sotto</h6>
                                <img src="jcaptcha.jpg" /> <br><br>
                                <input type="text" name="jcaptcha" value="" placeholder="captcha"/>
                                <br>
                            </div>
                        </div>
                        <div class="row-fluid show-grid">
                            <div class="span12">
                                <button class="btn btn-primary" type="submit">Registrati</button>
                                &nbsp;&nbsp;
                                <a href="javascript:history.back()">
                                    <button class="btn btn-primary">Back</button> 
                                </a>
                            </div>
                        </div>
                </form>
            </div>
        </div>
    </body>
</html>

